Mullen(Gibson), Margaret Fern 'TOWJV OF QQE9v8 Q1
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURy, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director (r •
JLfo�
Name Mh. hit+ „� F h Case # CS
Date of Cremation Ft brv&r1 3 ZOR.
Time Cremation Started 1: C n
Time Cremation Completed /u 00J1 n-1
Type of Container (QI)1.) 219 4 vl
Remarks :
11 PIM 46= v 41—i 35 1'1
55
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477
• Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,In accordance with and subject to its Rules and Regulations to
cremate the remains of:
Margaret Fern (Gibson) Mullen F
(Name) (Sex)
Fort Hudson HCF Fort Edward NY 12828-
(Street) (City) (State) (Zip Code)
who died on 30th day of January 20 1 0
at FORT HUDSON HEALTH CARE FACFort Edward NY
(Piece) (Address)
Name and address of nearest living relative or name of person artttormrag cremation:
Virginia Dean 11 Dean Drive, Queensbury, NY
(Name) (Address)
Relationship to the deceased N i e c e
Name of Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the best of my knowledge,the deceased(t>a or(has no) ,defibdlator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.
I certify that I have fill power and authorization to arrange for the cremation of the remains end to direct the disposition of the
cremated remains,that any personal possessions have either been removed or may be destroyed,end agree to protect defend end
save harmless Pine View Crematorium from any end all claims and demands for lose or damages which may be made against them
by d or connected with the cremation of said remains as directed„whether such claims or demands are or are not wholly
-T - false«
68 Main Street, Hudson Falls, NY
( )
11 Dean Dr. , Queensbury, NY
/ (Signature and Address of Relative or Legal Representative)
Signed on this date: 11.( ID
•
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows._
Mail to
Other arrangements-Please specify:
if pulverization of Cremated remains is requested,check here XX
Revision:April 18,2007